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Jeff Kaufhold, MD FACP Nephrology Associates of Dayton Oct 2013

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Presentation on theme: "Jeff Kaufhold, MD FACP Nephrology Associates of Dayton Oct 2013"— Presentation transcript:

1 Jeff Kaufhold, MD FACP Nephrology Associates of Dayton Oct 2013
ICD 10 and Nephrology Jeff Kaufhold, MD FACP Nephrology Associates of Dayton Oct 2013

2 Make the Diagnosis of Kidney Disease
Criteria The ICD9 Code for CKD is 585.x where x = stage The ICD 9 Code for ARF is 584.9 Decreased kidney function eGFR of <60 ml/min/1.73 m2 for ≥ 3 months Abnormal urinalysis including the presence of proteinuria or hematuria Request a spot urine protein/creatinine ratio (Normal is <30 mg/g) Document an abnormal Renal Imaging Study Based on the KDOQI guidelines there are specific findings to make the diagnosis of CKD and this information will be helpful in assessing the need for Timely Referral.

3 ICD 9 and 10 history ICD 9 developed by WHO
ICD 9 Clinical Modification developed for US in 1979. CPT (clinical Procedural Terminology) codes used for ambulatory reporting. ICD 10 developed in 1990’s ICD 10 codes are now available in EPIC as of Oct Mandatory use of ICD 10 is Oct 1, 2014. CPT codes will continue to be used for physician practice settings/ office billing

4 ICD 10 after Oct 1 2014 Required for HIPAA transactions
ICD 10 CM (Diagnosis) codes Required for diagnosis of all services inpt or outpt ICD 10 PCS (procedure) codes will be required on inpt claims EPIC is starting the migration from ICD 9 to 10 codes now, and EPIC Premier inpt billing function includes the new ICD 10 coding structure.

5 ICD 10 Changes Over 50% of new Dx are musculoskel, and 36 % are to distinguish R from L

6 ICD 10 Changes Up to 7 characters
Includes complication, severity, sequelae and other disease related parameters Includes laterality Includes initial or subsequent encounter code Improved consistency of terminology Combination codes are common i.e DM 2, controlled with renal manifestation Has space holders for expansion

7 ICD 10 PCS coding for inpts
D B 5 8 Z X Section Body system Root operation Body part Approach Device qualifier Med/Surg GI Excision Esophagus Natural opening, endoscopic No device implanted Diagnostic ICD 9 ; EGD with excisional biopsy, ICD 10 0DB58ZX Endoscopic esophageal excision via natural or artificial opening

8 Most common issues in ICD 10
Laterality – as you code, EPIC will prompt you if right or left is required Trimester specific Many new orthopedic codes Specificity is increased dramatically, so physician documentation must be more specific too.

9 Top 5 Clinical Documentation Issues
CHF Sepsis Renal Failure Pneumonia Respiratory Failure Don’t use “Other” or accept a nonspecific diagnosis like DM, when a more specific term exists: “DM 2 controlled with renal manifestation”

10 ICD 10 codes Epic is migrating codes so over next year you may search using known ICD 9 codes Can keep your PMHx and ongoing problem list NONSPECIFIC, But your visit diagnosis list must be as specific, detailed, and include as many modifiers/ comorbidities/severity codes as possible

11 Common Diagnoses ICD 9 DM 2 no mention of controlled or complication DM 1 with renal manifestation ICD 10 E11.65 DM 2 with hyperglycemia E10.21 DM 1 with nephropathy AND E10.65 DM1 with hyperglycemia

12 Top 5 Clinical Documentation issues
Condition Common issues Financial impact CHF Acute vs Chronic, systolic vs diastolic DRG 684 Renal failure without major complication or comorbidity Sepsis Sepsis, severe sepsis, SIRS, bacteremia $ 3609 Renal Failure Acute vs chronic Stage with RIFLE criteria or CKD stage With ATN is important DRG 682 renal failure with major complication and comorbidity Pneumonia Cause / specific bacteria Aspiration, simple vs complex, laterality $ 9340 Respiratory Failure Acute vs chronic, resp distress vs resp failure

13 Quality Performance hinges on Documentation
For inpts affects the hospital quality score For our pts affects our practice score Lack of clear documentation results in inappropriate assignment of complication codes for expected consequence of renal disease Improved documentation results in lower reported complication rates, higher complexity/ comorbidity scores reflect sicker population we care for.

14 Specific details for pts with ARF and CKD
DM Type I or II, controlled or uncontrolled Use A1c over 6.5 as uncontrolled With renal manifestation Hypertension With nephropathy CKD stages 1-5, use ESRD for pts on dialysis in the medicare ESRD program. AKI with ATN

15 Specific details for pts with ARF and CKD
AKI with ATN Urine findings ATN casts Oliguria Creatinine over 2.5 or > 2X baseline Were they pre-renal? Does pt have TIN? Complications of renal failure Anemia of CKD Secondary hyperparathyroidism of renal origin Protein calorie malnutrition Severe = albumin less than 3.0

16 Estimated impact on physician practice
% increase in denials Differences in authorization and referral triggers Increased scrutiny of documentation Impact on contracting/ preferred provider status based on severity of illness as reflected in coding.

17 ICD 10 and EPIC ICD 10 diagnosis calculator goes live on Premier Epic Oct Training modules available on Healthstream Some codes require specific information, and a coding window will open to fill in R vs L, initial visit vs followup, sequelae. Many codes won’t require more specificity, but for visits we should try to be as specific as possible.

18 ICD 10 and EPIC Many codes won’t require more specificity, but for visits we should try to be as specific as possible. We can double click item on the problem list like DM, HTN, Other disorder of renal etc, and make it more specific, without losing / deleting associations.

19 Diabetes codes E DM due to underlying condition with diabetic nephropathy E Drug or chemical induced DM with DM CKD E DM I with Diab. Neph E DM II with Diabetic Nephropathy E13.22 Other specified DM with Diabetic CKD

20 CKD Codes N18.1 CKD stage 1 N18.2 CKD Stage 2 N18.3 CKD Stage 3
N18.6 ESRD N18.9 CKD unspecified

21 CKD and DM codes Code the DM first, then the stage:
E10.22 Type I DM with nephropathy N18.6 ESRD Same for Hypertensive Kidney Disease I12 hypertensive Kidney disease N18.4 CKD Stage 4 If pt has heart and kidney disease, use I13 hypertensive Heart and CKD CHF uses I 50 codes

22 HTN and CKD Codes I12.0 Hypertensive CKD with Stage 5 or ESRD
I12.9 “” “” with stages 1-4 CKD I Hypertensive Heart and CKD without heart failure, Stages 1-4 I Hypertensive Heart and CKD without heart failure, Stage 5 or ESRD I13.2 Hypertensive Heart and CKD with heart failure, Stage 5 or ESRD

23 Nephrology Codes N 0 – 8 Glomerulonephritis
N 10 Interstitial Nephritis N 17 ARF N 18 CKD N 20 Kidney stone N Bladder disorders N 40 BPH

24 Nephrology Codes PCKD Q 61.3 Acquired cyst N 28.1
Q Congenital Malformations of the urinary System R 80 Proteinuria R 81 Glycosuria R 60 Edema

25 Nephrology Codes for ICD 10
Electrolyte disorders: E 87 High K E 87.5 Protein Calorie Malnutrition E 43 severe E 44 Mild to Moderate Secondary hyperparathyroidism of renal origin N 25.81

26 Nephrology Common Codes
Anemia of CKD D 63.1 Lupus Nephritis SLE M 32 – not completely mapped yet Renal transplant – has not yet mapped (as of Oct 2013) Dysfunction would be coded with the ARF or CKD code to denote pts renal function at time of visit N 17.9 ARF N 18.3 CKD stage 3

27 Transplant Specifics Just because your patient has a transplant, they still have Chronic Kidney disease. List the transplant List the CKD stage for chronic allograft dysfunction List acute allograft dysfunction if present List the cause of their underlying CKD/ESRD List comorbidities and complications Are they anemic due to Cellcept use? Did they develop NODAT? Doc talk, Precyse University, Oct 2013

28 PCKD specifics PCKD Q 61.3 Acquired cyst N 28.1
Q Congenital Malformations of the urinary System Autosomal Dominant or recessive? Liver /other cysts?

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